AMERICAN THYROID ASSOCIATION
www.thyroid.org
Graves Disease
WHAT IS THE THYROID GLAND?
The thyroid gland is a butterfly-shaped endocrine gland
that is located in the lower front of the neck. The thyroid
makes thyroid hormones, which are secreted into the
blood and then carried to every tissue in the body. Thyroid
hormones help the body use energy, stay warm and
keep the brain, heart, muscles, and other organs working
appropriately.
WHAT IS GRAVES DISEASE?
Graves disease is an autoimmune disease that leads
to a generalized overactivity of the entire thyroid gland
(hyperthyroidism). It is the most common cause of
hyperthyroidism in the United States. It is named after
Robert Graves, an Irish physician, who described this form
of hyperthyroidism about 150 years ago. It is 7-8 times
more common in women than men.
WHAT CAUSES GRAVES DISEASE?
Graves disease is triggered by a process in the bodys
immune system, which normally protects us from foreign
invaders such as bacteria and viruses. The immune
system destroys foreign invaders with substances
called antibodies produced by blood cells known as
lymphocytes. Sometimes the immune system can be
tricked into making antibodies that cross-react with
proteins on our own cells. In many cases these antibodies
can cause destruction of those cells. In Graves
disease these antibodies (called the thyrotropin receptor
antibodies (TRAb) or thyroid stimulating immunoglobulins
(TSI) do the opposite they cause the cells to work
overtime. The antibodies in Graves disease bind to
receptors on the surface of thyroid cells and stimulate
those cells to overproduce and release thyroid hormones.
This results in an overactive thyroid (hyperthyroidism).
WHAT ARE THE SYMPTOMS OF GRAVES
DISEASE?
Hyperthyroidism
The majority of symptoms of Graves disease are caused
by the excessive production of thyroid hormones by the
thyroid gland (see Hyperthyroidism brochure). These
may include, but are not limited to, racing heartbeat,
hand tremors, trouble sleeping, weight loss, muscle
weakness, neuropsychiatric symptoms and heat
intolerance.
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the American Thyroid Association
Eye disease
Graves disease is the only kind of hyperthyroidism
that can be associated with inflammation of the eyes,
swelling of the tissues around the eyes and bulging
of the eyes (called Graves ophthalmopathy or
orbitopathy). Overall, a third of patients with Graves
disease develop some signs and symptoms of Graves
eye disease but only 5% have moderate-to-severe
inflammation of the eye tissues to cause serious or
permanent vision trouble. Patients who have any
suggestion of eye symptoms should seek an evaluation
with an eye doctor (an ophthalmologist) as well as their
endocrinologist.
Eye symptoms most often begin about six months
before or after the diagnosis of Graves disease has
been made. Seldom do eye problems occur long after
the disease has been treated. In some patients with
eye symptoms, hyperthyroidism never develops and,
rarely, patients may be hypothyroid. The severity of
the eye symptoms is not related to the severity of the
hyperthyroidism.
Early signs of trouble might be red or inflamed eyes, a
bulging of the eyes due to inflammation of the tissues
behind the eyeball or double vision. Diminished vision or
double vision are rare problems that usually occur later,
if at all. We do not know why, but problems with the eyes
occur much more often and are more severe in people
with Graves disease who smoke cigarettes.
Skin disease
Rarely, patients with Graves disease develop a lumpy
reddish thickening of the skin in front of the shins known
as pretibial myxedema (called Graves dermopathy).
This skin condition is usually painless and relatively mild,
but it can be painful for some. Like the eye trouble of
Graves disease, the skin problem does not necessarily
begin precisely when the hyperthyroidism starts. Its
severity is not related to the level of thyroid hormone.
 AMERICAN THYROID ASSOCIATION
Graves Disease
HOW IS THE DIAGNOSIS OF GRAVES
DISEASE MADE?
The diagnosis of hyperthyroidism is made on the basis
of your symptoms and findings during a physical exam
and it is confirmed by laboratory tests that measure
the amount of thyroid hormones (thyroxine, or T4, and
triiodothyronine, or T3) and thyroid-stimulating hormone
(TSH) in your blood (see the Hyperthyroidism brochure).
Clues that your hyperthyroidism is caused by Graves
disease are the presence of Graves eye disease and/or
dermopathy (see above), a symmetrically enlarged thyroid
gland and a history of other family members with thyroid
or other autoimmune problems, including type 1 diabetes,
rheumatoid arthritis, pernicious anemia (due to lack of
vitamin B12) or painless white patches on the skin known
as vitiligo.
The choice of initial diagnostic testing depends on
cost, availability and local expertise. Measurement of
antibodies, such as TRAb or TSI, is cost effective and if
positive, confirms the diagnosis of Graves disease without
further testing needed. If this test is negative (which can
also occur in some patients with Graves disease), or if this
test is not available, then your doctor should refer you to
have a radioactive iodine uptake test (RAIU) to confirm the
diagnosis.
Also, in some patients, measurement of thyroidal blood
flow with ultrasonography may be useful to establish the
diagnosis if the above tests are not readily available.
HOW IS GRAVES DISEASE TREATED?
The treatment of hyperthyroidism is described in detail in
the Hyperthyroidism brochure. All hyperthyroid patients
should be initially treated with beta-blockers. Treatment
options to control Graves disease hyperthyroidism include
antithyroid drugs (generally methimazole [Tapazole],
although propylthiouracil [PTU] may be used in rare
instances such as the first trimester of pregnancy),
radioactive iodine and surgery.
Antithyroid medications are typically preferred in patients
who have a high likelihood of remission (women, mild
disease, small goiters, negative or low titer of antibodies).
These medications do not cure Graves hyperthyroidism,
but when given in adequate doses are effective in
controlling the hyperthyroidism.
Further details on this and other thyroid-related topics are available in the patient thyroid
information section on the American Thyroid Association website at www.thyroid.org.
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the American Thyroid Association
For information on thyroid patient support organizations, please visit the
Patient Support Links section on the ATA website at www.thyroid.org
www.thyroid.org
If methimazole is chosen, it can be continued for 12-18
months and then discontinued if TSH and TRAb levels
are normal at that time. If TRAb levels remain elevated,
the chances of remission are much lower and prolonging
treatment with antithyroid drugs is safe and may
increase chances of remission. Long term treatment of
hyperthyroidism with antithyroid drugs may be considered
in selected cases.
If your hyperthyroidism due to Graves disease persists
after 6 months, then your doctor may recommend
definitive treatment with either radioactive iodine or
surgery.
If surgery (thyroidectomy) is selected as the treatment
modality, the surgery should be performed by a skilled
surgeon with expertise in thyroid surgery to reduce the risk
of complications.
Your doctor should discuss each of the treatment options
with you including the logistics, benefits and potential side
effects, expected speed of recovery and costs. Although
each treatment has its advantages and disadvantages,
most patients will find one treatment plan that is right
for them. Hyperthyroidism due to Graves disease is, in
general, controllable and safely treated and treatment is
almost always successful.
WHAT WILL BE THE OUTCOME OF
TREATMENT?
If you receive definitive treatment for your Graves
hyperthyroidism (such as radioactive iodine or surgery),
you will eventually develop hypothyroidism (underactive
thyroid). Even if you are treated with antithyroid drugs
alone, hypothyroidism can still occur. Your doctor will
check your thyroid function tests frequently to assess
thyroid function following treatment. When hypothyroidism
occurs, you will need to take a thyroid hormone tablet
once a day at the right dose (see Hypothyroidism
brochure).
OTHER FAMILY MEMBERS AT RISK
Graves disease is an autoimmune disease and has a
genetic predisposition. However, no specific gene has
been identified for screening to date.
FURTHER INFORMATION